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Prostate Cancer Therapy Explained

Monday, September 29, 2008 at 9:19 PM

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When a man is diagnosed with prostate cancer, the treatment choices can be dizzying. In conversation with doctors at the Cleveland Clinic, ideastream's Gretchen Cuda clears up the confusion about the latest prostate cancer therapies.

The bad news has been delivered. It’s cancer.  The question is now what?  Should the prostate be surgically removed? Frozen? Irradiated? The best choice depends on the individual, explains Eric Klein who directs the center for Urologic Oncology at the Cleveland Clinic.  And in some cases, the best choice may be just to keep an eye on things.

KLEIN: Now we use a strategy in many patients called active surveillance where they are monitored if they meet the appropriate criteria and we don’t treat them unless their cancer progresses a little bit.  And we believe we can identify patients who will still be curable then. The advantage to that approach is that it avoids the side effects of treatment.

It might seem counter-intuitive or even foolish to not aggressively treat cancer, but Klein says tumors in the prostate grow very slowly - sometimes taking a decade or more before they become problematic.  For a man in his mid-fifties, whose cancer has been caught very early it can be safely monitored. And for a man in his late 70s or 80s, the chances of dying from another cause outweigh the chances of dying from prostate cancer.  Still, the psychological effect of knowing the cancer is there often overshadows the statistics.

KLEIN:  Most men who are newly diagnosed with prostate cancer, even if they qualify for active surveillance, chose to be treated because of the worry that an untreated cancer might ultimately be a problem

There are more than 20 different treatment choices, and no head-to head studies to compare the effectiveness of one over another. 

KLEIN: All of them have their pros and cons.  Because the prostate is where it is anatomically, all of those treatments cause some form of urinary symptoms and all of them have the potential to cause difficulty with erections.

Not exactly the sort of words most men want to hear.  Surgery -also known as a radical prostatectomy is the most extreme option, and probably the option with the most risks, since nerves can be cut resulting in impotence. But in recent years surgeons have learned how to avoid the nerves, minimizing this risk for many patients.  And for some men surgery provides a peace of mind that other options don’t.  Derek Rhagavan is the director of the Cleveland Clinic’s Taussig Cancer Center.

RHAGAVAN: The attraction of surgery is that you have a little bit of security knowing it’s all out sitting in a bucket or a pot somewhere.  You kind of feel that the cancer has been totally removed.

Another benefit says Rhagavan is it also allows both the surgeon and pathologists to look at all of the cancer up close, and determine if the patient would benefit from additional therapies like radiation following surgery.  An alternative to surgery is radiation alone. It’s far less invasive, and there’s no actual cutting.  Rhagavan explains one of the most recent radiation treatments, called brachytherapy - a technique where the tumor is killed inside out by inserting little radioactive particles inside it.

RHAGAVAN: There is no big open operation but you’re actually under an anesthetic while they stick them in through a kind of a needle device.

He assures me that implanted radioactive particles are dangerous ONLY to the cancer cells. 

RHAGAVAN:  They’re very carefully designed so the penetration of the radiation is very short.  Just a couple of millimeters so once you put them in the prostate you’re not walking around being radioactive for everyone around you.

Prostate tumors can also be treated by freezing, or with hormone therapy - or a combination of several different treatments - it all depends on the patient, his comfort level with the various risks, and the extent of his individual cancer. Rhagavan says there is no one right choice - but he does have one piece of advice

RHAGAVAN: Get a second opinion.  It might be in the same institution it might be somewhere else, but make sure that you are not just hearing one person tell the story, listen to it being said a number of different ways. 

Gretchen Cuda, 90.3

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